The surgeon and the oncologist in non-small cell lung cancer (NSCLC)

Lung cancer is the leading cause of cancer death in many countries. Despite major efforts to reduce smoking rates, lung cancer continues to claim more lives than the next three major cancers combined. Over the past 10 years, in the Western World the incidence of lung cancer in men has begun to decline but in women it is expected that lung cancer will continue to rise. Moreover, the number of patients affected by lung cancer continues to increase in developing countries and up to 50% of new lung cancer cases occur in former smokers and those who have never smoked [1]. Despite the recent developments in the care of this disease and in the field of cancer research, the prognosis for patients with lung cancer remains dismal, with an overall five-year survival rate of 14% [2]. The poor results have encouraged the attempt to associate all available therapeutic arms: at present all curable tumors (except for the stage Ia) are treated by surgery and systemic chemotherapy. Therefore, a strict collaboration is necessary between the oncologist and the surgeon. It is very important to perform an accurate locoregional staging to assess the gold-standard treatment and the resectability of the neoplasia. Indeed an incomplete resection is not useful in NSCLC. The methods in Clinical staging widely vary. The basic chest X-ray can show a paralysis of the emidiaphragm – generally due to unresectable T4 tumors and/ or bulky N2–N3 disease. The CT-scan is fundamental to define the clinical staging (TNM) of the tumor: it allows to evaluate the exact local extension of the primary tumor (T factor) and it can determine the lymph-node involvement (N factor) based on their size (even if the use of a cut-off of 10–15 mm for normal nodes provided sensitivity and specificity for detecting nodal metastases of only 40% to 70%) [3–4]. The Nuclear Magnetic Resonance (NMR) is useful to obtain specific information about the involvement of great vessels, diaphragm and chest wall. The Positron-emission tomography (PET) is emerging as an important non-invasive test for mediastinal assessment: it is significantly better than CT-scan for the detection of N1 or N2/N3 disease and it can prevent non-therapeutic thoracotomy. However, a positive PET for mediastinal nodes must be confirmed by tissue acquisition, because positive predictive value is only 56% [5]. Bronchoscopy, with Trans Bronchial Needle Aspiration (TBNA), or mediastinoscopy are considered the gold standard for invasive mediastinal lymph-node evaluation. Video-assisted thoracic surgery (VATS) and anterior mediastinothomy are the procedures of choice for invasive mediastinal evaluation in the aorto-pulmonary (A-P) window. Moreover, VATS is complementary to cervical mediastinoscopy because it helps to stage the lymph nodes in the A-P window (#5, 6), as well as the para-esophageal (#8) and the pulmonary ligament (#9) lymph nodes. VATS is also extremely useful to exclude malignant pleural effusions in otherwise operable patients. This examination can be done in the operating room immediately prior to formal thoracotomy [6]. Surgery remains the best treatment modality for potential cure in patients with NSCLC. Surgical resection is the primary therapy for stage I/II NSCLC. Reported survival data range between 24% and 30% for stage-IIB patients and approximately between 61% and 79% for stage IA patients, with distant metastasis being the dominant form of relapse after surgical resection. There is a strong rationale that supports the concept of the addition of systemic therapy to surgery either preoperatively or postoperatively even in patients with early-stage disease. Randomised trials of adjuvant chemotherapy show an absolute survival benefit of 12–15% for patients receiving postoperative chemotherapy and these results suggest that adjuvant platinum-based chemotherapy may become the new standard of care in resected stages IB-II NSCLC [7–8]. The addition of chemotherapy to local treatments such as radiation or surgery is now considered the standard of care in theWesternWorld for patients with stage III [1]. Stage III comprises a fairly heterogeneous group of tumors and the optimal approach is still debated in these subgroups. In the IIIA (T3N1) group the role of surgery is clearer and these patients should undergo adjuvant chemotherapy if they have a good performance status (PS). Radiotherapy should be added only when the surgeon feels that resection margins were unusually close [9]. The disappointing s y m p o s iu m